ASSESSMENT DIAGNOSIS PLANNING N.

INTERVENTION RATIONALE EVALUATION

PROBLEM: >Nutrition SHORT TERM: INDIPENDENT: >After 3 days
VOMITING imbalanced >After 3 days >Avoid foods that >Might of nursing
less than body of nursing might cause or increase intervention
SUBJECTIVE: requirements intervention exacerbate abdominal the client will
“Nagsusuka related to the patient abdominal cramping. be able to
ang anak ko vomiting will be able to cramping like maintain usual
“as verbalized maintain usual caffeinated weight.
by the patient. weight. beverages,
chocolate, orange
juice.
OBJECTIVE: LONG TERM: >Eliminate smells >Reduces
>Irritability >After 2 from the gastric
>weakness weeks of environment. stimulation
nursing and vomiting
intervention responses.
the patient >Asses abdominal >Indicates
v/s was able to frequently for return of
T:37 maintain return to softness, normal vowel
P:98 normal appearance of function and
R:20 weight. normal sound, ability to
BP:110/80 and passage of resume oral
flatus . intake.
>Weight daily.

>Initial looses
or gains
reflect
>COLLABORATIVE changes in
: hydration.
>Advance diet as >Careful
tolerated. progression of
diet when
intake is
measured risk
of gastric
irritation.

ASSESSMENT DIAGNOSIS PLANNING N.INTERVENTION RATIONALE EVALUATION

PROBLEM: Acute pain SHORT TERM: INDEPENDENT: >Provides >After 8 hours
ABDOMINAL related to After 8 hours >Asses pain, information to of nursing
PAIN. factors such as of nursing noting location, aid in intervention.
abdominal intervention intensity (scale determining The patient
SBJECTIVE: pain . the patient of 0-10) choices of pain will be
“Masaki tang will be duration. effectiveness relieved or
tiyan ng anak relieved or of controlled.
ko “as controlled. interventions.
vervalized by >Provides >Promotes
the patient LONG TERM: comfort measure relaxation, and
mother. >After 2 weeks like back rub, may enhance
of nursing helping patient coping
OBJECTIVES: intervention assume position abilities.
>Facial the patient of comfort.
grimace pain will be suggest use of
>Restlessness done. relaxation
techniques and
deep breathing
exercises.
v/s
T:38 COLLABORATIVE:
P:55 >Asses patient to >Promotes
R:18 reduce pain muscle
BP:120/80 relaxation.

ASSESSMENT DIAGNOSIS PLANNING N.INTERVENTIO RATIONALE EVALUATION

N
PROBLEM: >Injury risk for SHORT TERM INDEPENDENT; >After 1 hour
NOSE hemorrhage >After 1 hour >Monitor the >An increase of nursing
BLEEDING related to of nursing blood pressure . impulse with interventions,
clotting factor interventions decrease the client was
SUBJECTIVE: the patient blood pressure able behaviors
“Dumidugo will be to can indicate that reduce
ang ilong ng demonstrate loss of the risk for
anak ko”as behavior that circulating bleeding.
verbalized by reduce that blood volume.
the patient risk for >Asses for the >The GI tract
mother. bleeding sign and (esophagus
symtoms of GI and rectum) is
OBJECTIVES: bleeding, check the most usual
>Weakness for secretions. source of
>Irritability Color and bleeding of its
>Restlessness consistency of mucosal
stool and fragility.
v/s vomitus.
T:38 >Encourage use >Rectal and
P:55 of soft tooth esophageal
R:18 brush, avoiding vessels are
BP:120/80 straining for most
stool, and ,vulnerable to
peaceful nose rapture.
bleeding.
>Recommended >Prolongs
avoidance of coagulation,
aspirin potentiating
containing risk of
products. hemorrhage.

COLLABORATIVE:
>Monitor >Indicators of
clotting factor. anemia, active
bleeding , or
impending
complication.